Advanced Pharmacy Australia general medicine standards: paving the way for multidisciplinary care and collaboration

IF 1 Q4 PHARMACOLOGY & PHARMACY
Ak Kar Aung BMedSci, MBBS, FRACP, MPHTM, Michelle Downie MBCHB, FRACP, Leigh-anne Shannon BA, MAICD, Douglas F. Johnson MBBS (Hons), BComm, PhD, DTM&H, GChPOM, FRACP
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While designed to improve patient flow through the hospital systems, evolving models that institute transitions through different care teams at different phases of the patient's journey, such as acute medical units/streaming teams in emergency departments, inpatient teams during hospital admission, early discharges via Hospital in the Home programs or community/outpatient teams, may potentially lead to multiple handovers, compartmentalisation and fragmentation of care, thus creating further vulnerable points in medication prescription and management.</p><p>General Medicine is a team sport. The diversity and complexity in General Medicine undoubtedly call for a multidisciplinary approach, with emphasis on shared decision making across the disciplines, to deliver high-value personalised care to achieve the best outcomes for the patients. Hospital pharmacists have always been a major part of multidisciplinary care for general medical patients. A large body of evidence exists to support the role of advanced clinical pharmacist services in caring for medical inpatients, in areas of medication charting, anticoagulation and thromboprophylaxis stewardship, psychotropic stewardship, vaccination, deprescribing, medication safety and adverse drug reactions, glycaemic management, opioids stewardship, and antimicrobial stewardship and allergy delabelling.</p><p>Specifically for General Medicine in the local context, medication reconciliation and the Partnered Pharmacist Medication Charting model have been shown to reduce discharge prescription errors and facilitate safer discharges and have now become the standard of care in many major hospitals across Australia.<span><sup>2</sup></span> Pharmacists play a central and critical role in ensuring smooth transitions of care in the patient's journey (e.g. discharge from hospital to community), which pose high risk and vulnerable points for medication errors.<span><sup>3</sup></span> Pharmacists are also contributing to ongoing care of patients in the community through outpatient services and bed-substitution models of care (e.g. Hospital in the Home). 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引用次数: 0

Abstract

General Medicine is the largest provider of acute inpatient care in Victoria, and possibly also in the wider Australia and Aotearoa New Zealand.1 Clinicians in General Medicine, including pharmacists, are trained to care for patients who are often elderly and frail, with multiple comorbidities, undifferentiated problems, and complex physiological and psychosocial needs. General Medicine services also care for vulnerable and marginalised patient populations, such as First Nations peoples, people experiencing homelessness, migrant and refugee populations, and people who inject drugs. General Medicine is also frequently involved in the care of perioperative patients, especially for those whose surgical issues are managed non-operatively, and patients who are pregnant with medical issues.

Management of general medical patients poses unique challenges. The specialty requires both breadth and depth of knowledge, concerning every organ system and their intricate interactions, and yet, the available best practice evidence-based guidelines are often single organ focused and may not directly apply to general medical patients. This is because patients who have competing comorbidities and are often not included due to highly selective exclusion criteria in major clinical trials. Patient presentations in General Medicine can range widely from being undifferentiated and acutely unwell, to management of stable chronic diseases which impact their lifestyle. There are also added layers of patient complexity such as cognitive, functional, and psychosocial issues which impact on access to care, medicine compliance, and health literacy. Additionally, certain considerations must be given in the management paradigm of some patient groups, for instance, prioritising and optimising quality of life for patients with advanced age and comorbidities, minimising medication adverse effects and related harm and reducing polypharmacy through deprescribing, while ensuring adherence to essential and critical medications. The care delivered must be of high quality and high value, not only based on the best available evidence, but also be holistic and patient-centred to tailor individual needs, circumstances, psychosocial, and physiological vulnerabilities. All clinicians in General Medicine have the obligation to minimise and eliminate low-value care options, that will not make any difference to patient outcomes, and may in fact result in harm, with significant associated economic and environmental costs.

From the systems perspectives, anecdotally, the models of care in General Medicine have been rapidly changing over the last two decades to meet the increasing service demands and to alleviate bed access pressures. While designed to improve patient flow through the hospital systems, evolving models that institute transitions through different care teams at different phases of the patient's journey, such as acute medical units/streaming teams in emergency departments, inpatient teams during hospital admission, early discharges via Hospital in the Home programs or community/outpatient teams, may potentially lead to multiple handovers, compartmentalisation and fragmentation of care, thus creating further vulnerable points in medication prescription and management.

General Medicine is a team sport. The diversity and complexity in General Medicine undoubtedly call for a multidisciplinary approach, with emphasis on shared decision making across the disciplines, to deliver high-value personalised care to achieve the best outcomes for the patients. Hospital pharmacists have always been a major part of multidisciplinary care for general medical patients. A large body of evidence exists to support the role of advanced clinical pharmacist services in caring for medical inpatients, in areas of medication charting, anticoagulation and thromboprophylaxis stewardship, psychotropic stewardship, vaccination, deprescribing, medication safety and adverse drug reactions, glycaemic management, opioids stewardship, and antimicrobial stewardship and allergy delabelling.

Specifically for General Medicine in the local context, medication reconciliation and the Partnered Pharmacist Medication Charting model have been shown to reduce discharge prescription errors and facilitate safer discharges and have now become the standard of care in many major hospitals across Australia.2 Pharmacists play a central and critical role in ensuring smooth transitions of care in the patient's journey (e.g. discharge from hospital to community), which pose high risk and vulnerable points for medication errors.3 Pharmacists are also contributing to ongoing care of patients in the community through outpatient services and bed-substitution models of care (e.g. Hospital in the Home). Integrated General Medicine pharmacy services are thus critical to optimise the care of patients.

Additionally, hospital pharmacists play a leading role in clinical governance and innovation, through participation in audit and research activities, as well as mortality and morbidity reviews, and development of novel models of care. Active contribution by pharmacists to the departmental interdisciplinary education activities can further enhance clinical practice through sharing experiences, knowledge, and team development. The multidisciplinary involvement of pharmacists at every step of the patient's journey within wider team structures in General Medicine, can thus improve patient care and outcomes, improve hospital flow, reduce length of stay, reduce readmissions and enable safe transition of patients between care settings, and should strongly be promoted.

The Internal Medicine Society of Australia and New Zealand (IMSANZ) is a society that supports all healthcare professionals, including pharmacists working in General Medicine across Australia and Aotearoa New Zealand and the Pacific.4 IMSANZ welcomes and endorses the General Medicine Standards by Advanced Pharmacy Australia (AdPha) published in this issue of the Journal of Pharmacy Practice and Research.5 The best practice principles and professional standards outlined in this document clearly defines the importance of pharmacists in the care of General Medicine patients and the roles and responsibilities of pharmacists working within general medical units across both countries, including specialist pharmacists trained in General Medicine. It places high level emphasis on patient-centred approach to medication management and promotes the importance of interdisciplinary shared decision-making in patient care. Additionally, the document provides advocacy and guidance for staffing, training and qualification requirements, as well as workforce development to meet the complex needs of general medical patients. The document highlights areas where opportunities exist for IMSANZ and AdPha to further collaborate on education, research, workforce development, and innovations in models of care.

Translating the General Medicine Standards into practice will not be without due challenges. Currently, there is limited understanding of the workforce distribution, patient mix, scope of work and associated workload in resource-limited regional, rural and remote general medical settings, as well as in private sectors, across Australia to fully inform if certain approaches are feasible, beneficial, or cost effective. Further robust research is needed to provide advocacy at state and federal levels to establish integrated general medical pharmacy services in resource-limited settings. Additionally, hospital pharmacists need to be highly flexible and adaptable to the rapidly changing and diverse landscape of General Medicine, often driven by high service demands. In such high-pressure environments, processes must also be established to safeguard the pharmacists' health and well-being. The evolving roles, responsibilities and workforce structures of pharmacists in General Medicine must thus be informed by continual needs analysis, research, and health economics analysis to ensure the development of sustainable models of care, both economically and environmentally, that provide only high-value care to our patients.

Ak Kar Aung, Michelle Downie, Douglas F. Johnson all hold unpaid positions on the Board of Directors of the Internal Medicine Society of Australia and New Zealand (IMSANZ). Leigh-anne Shannon holds a salaried position at IMSANZ. Michelle Downie has received payment from Novo Nordisk and Boehringer Ingelheim for presentations and/or educational events. The authors declare that they have no additional conflicts of interest.

Ak Kar Aung: conceptualisation, writing – original draft, writing – reviewing and editing. Michelle Downie: conceptualisation, writing – original draft, writing – reviewing and editing. Leigh-anne Shannon: conceptualisation, writing – original draft, writing – reviewing and editing. Douglas F. Johnson: conceptualisation, writing – original draft, writing – reviewing and editing.

Ethics approval was not required for this editorial as it did not contain any human data or participants.

Commissioned, not externally peer reviewed.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

先进的药房澳大利亚一般医学标准:为多学科护理和合作铺平道路
全科医学是维多利亚州最大的急性住院病人护理提供者,可能在更广泛的澳大利亚和新西兰奥特亚罗地区也是如此。1全科医学的临床医生,包括药剂师,接受过培训,以照顾通常是老年人和虚弱的病人,有多种合并症,未区分的问题,以及复杂的生理和社会心理需求。一般医疗服务还照顾弱势和边缘化患者群体,如第一民族、无家可归者、移民和难民人口以及注射吸毒者。普通医学也经常参与围手术期患者的护理,特别是那些手术问题不通过手术处理的患者,以及怀孕有医疗问题的患者。普通医疗病人的管理面临着独特的挑战。该专业需要知识的广度和深度,涉及每个器官系统及其复杂的相互作用,然而,现有的最佳实践循证指南往往是单一器官的重点,可能不直接适用于普通患者。这是因为在主要的临床试验中,由于高度选择性的排除标准,具有竞争性合并症的患者通常不包括在内。在普通医学中,患者的表现范围很广,从未分化和急性不适到影响其生活方式的稳定慢性疾病的管理。此外,患者的认知、功能和社会心理问题等复杂性也有所增加,这些问题影响到获得护理、药物依从性和卫生素养。此外,在某些患者群体的管理模式中必须考虑到某些因素,例如,优先考虑和优化老年和合并症患者的生活质量,最大限度地减少药物不良反应和相关危害,通过开处方减少多种药物,同时确保坚持使用基本和关键药物。所提供的护理必须具有高质量和高价值,不仅要基于现有的最佳证据,而且要全面和以患者为中心,以适应个人需求、情况、社会心理和生理脆弱性。全科医学的所有临床医生都有义务尽量减少和消除低价值的护理选择,这些选择不会对患者的预后产生任何影响,实际上可能导致伤害,并带来重大的相关经济和环境成本。从系统的角度来看,在过去的二十年里,为了满足日益增长的服务需求和减轻床位压力,全科医学的护理模式发生了迅速的变化。虽然旨在改善医院系统中的患者流动,但不断发展的模型在患者旅程的不同阶段通过不同的护理团队进行转换,例如急诊科的急症医疗单位/流团队,住院期间的住院团队,通过家庭医院计划或社区/门诊团队的早期出院,可能会导致多次移交,分隔和碎片化护理。从而造成了药物处方和管理的进一步薄弱环节。全科医学是一项团队运动。全科医学的多样性和复杂性无疑需要多学科方法,强调跨学科的共同决策,以提供高价值的个性化护理,为患者实现最佳结果。医院药师一直是全科病人多学科护理的重要组成部分。大量证据表明,先进的临床药师服务在护理住院患者、药物图表、抗凝和血栓预防管理、精神药物管理、疫苗接种、处方处方、药物安全和药物不良反应、血糖管理、阿片类药物管理、抗菌药物管理和过敏标签去除等领域发挥了作用。特别是对于当地的普通医学,药物调解和合作药剂师药物图表模式已被证明可以减少出院处方错误,促进更安全的出院,现在已成为澳大利亚许多主要医院的护理标准。2药剂师在确保患者旅途中的护理顺利过渡(例如从医院出院到社区)方面发挥着核心和关键作用。这些是药物错误的高风险和脆弱点药剂师还通过门诊服务和替代床位的护理模式(如家庭医院)为社区病人的持续护理作出贡献。因此,综合全科医学药房服务对于优化患者护理至关重要。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Journal of Pharmacy Practice and Research
Journal of Pharmacy Practice and Research Health Professions-Pharmacy
CiteScore
1.60
自引率
9.50%
发文量
68
期刊介绍: The purpose of this document is to describe the structure, function and operations of the Journal of Pharmacy Practice and Research, the official journal of the Society of Hospital Pharmacists of Australia (SHPA). It is owned, published by and copyrighted to SHPA. However, the Journal is to some extent unique within SHPA in that it ‘…has complete editorial freedom in terms of content and is not under the direction of the Society or its Council in such matters…’. This statement, originally based on a Role Statement for the Editor-in-Chief 1993, is also based on the definition of ‘editorial independence’ from the World Association of Medical Editors and adopted by the International Committee of Medical Journal Editors.
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